Claire Chesworth Kevin Barrett Clare Jenkins Kunal Patel Practice Manager: Catherine Garibaldi The Surgery 166 New Road Croxley Green Rickmansworth, WD3 3HD www.newroadsurgery.info Tel: 01923 604884 Family Doctor Services Registration (GMS1) Patient's details* MrMrsMissMs Surname* Date of birth* /Day /MonthYearDate First names* NHS No.* Gender* MaleFemale Previous surname/s Town and country* Home Address* Street Address Street Address Line 2 CityCounty Post Code Telephone number* Please help us trace your previous medical records by providing the following information. Address Street Address Street Address Line 2 CityCounty Post Code Name of GP practice while at that address* Address of previous GP practice* Street Address Street Address Line 2 CityCounty Postcode If you are from abroad, your first UK address where you registered with a GP Street Address Street Address Line 2 CityCounty Post Code If previously resident in UK, date of leaving -Day -MonthYearDate Date you first came /Day /MonthYearDate Were you ever registered with an Armed Forces GP Please indicate if you have served in the UK Armed forces and/or been registered with a Ministry of Defence GP in the UK or overseas RegularFamily Member (Spouse, Civil Partner, Service Child)VeteranFamily Member (Spouse, Civil Partner, Service Child) Address before enlisting Street Address Street Address Line 2 CityState / Province Postal / Zip Code Service or Personnel number: Enlistment date: /Day /MonthYearDate Discharge date: /Day /MonthYearDate Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services. If you need your doctor to dispense medicines and appliances I live more than 1.6km in a straight line from the nearest chemistI would have serious difficulty in getting them from a chemist Signature of patient Clear Signature on behalf of patient Clear Date of signature /Day /MonthYearDate What is your ethnic group? White: BritishIrishIrish TravellerTravellerGypsy/RomanyPolishOther White (please specify) Mixed: White and Black CarribeanWhite and Black AfricanWhite and AsianOther Mixed (please specify) Asian or Asian British: IndianPakistaniBangladeshiOther Asian (please specify) Black or Black British: CarribeanAfricanSomaliNigerianOther Black (please specify) Other ethnic group: ChineseFilipinoOther ethnic group (please specify) Not stated: Please select here if you wouldn't like to state your ethnicity Back Next New Patient Questionnaire Today's Date -Day -MonthYear Personal Details Title Surname* First Name (s)* Calling Name (if different) Previous name(s) (if any) Date of Birth -Day -MonthYearDate NHS Number Home Telephone Number Mobile Telephone Number If you are over 16 please put your own mobile phone number NOT parent/guardian's number Text Messaging Service We will send you text messages to remind you of appointments, enable you to cancel your appointmentsand receive updates regarding initiatives e.g. stop smoking. Please indicate if you wish to “opt in” to our text messaging service by ticking below I consent to be contacted by SMS text messaging on this mobile number Carers Do you look after someone?* If so, who? Children Only (12 months - under 16 year) Name(s) of parent(s), guardian(s) or carer(s) and their relationship to the child: Name(s) Relationship Please confirm that you hold parental responsibility for this child YesNo Home telephone number Mobile telephone number Accessible Information Do you have any information or communication needs relating to a disability, impairment or sensory loss? e.g. large print, braille, hearing loop etc or do you need a translator? General Health & Lifestyle Weight How much do you weigh?* Height How tall are you?* Blood Pressure (Patients over 18) Please use the machine in the surgery and hand the print-out to reception with this form. Please ask at reception if you need any help to use the machine. Systolic Diastolic Alcohol How much alcohol do you drink per week? Please fill in the assessment table shown below, selecting the response which applies to you for each question: Never Monthly or less 2-4 times per month 3-2 times per week 4+ times per week How often do you have a drink that contains alcohol? 1-2 3-4 5-6 7-8 10+ How many standard alcoholic drinks do you have on a typical day when you're drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often do you have 6 or more standard drinks on one occasion? Smoking Do you smoke? If so, how much per week? Have you ever smoked? If so, when did you stop? Print FormSubmit Should be Empty:
